symptoms may be confidently expected during the stage of infiltration.
The outlook is especially favorable in cases of puerperal subinvolution
in the absence of chronic inflammations of the endometrium and
parametrium. A perfect restitution of the uterus to its normal
condition is so seldom effected by any rational therapy that for
practical purposes this desirable result may be excluded from
consideration. Recidiva of the disease are liable to occur at any time.
TREATMENT.--Prophylaxis.--Very much can be done to prevent the
occurrence of chronic metritis. A careful consideration of the etiology
of the disease will at once suggest the principles of prophylactic
treatment. The conduct of the second stage of labor, the puerperium,
lactation, the hygiene of menstruation, are subjects especially
significant in this connection. Antecedent acute metritis and
endometritis under a rational therapy usually terminate in resolution,
and their pernicious influences as etiological factors may be avoided,
or at least modified, in the large majority of cases. The early
rectification of uterine flexions and displacement is urgently
indicated in view of the probable consequences.
Uncomplicated chronic metritis is such a rare affection that efforts at
curative treatment are seldom addressed to the condition of the
parenchyma, to the exclusion of the endometrium, perimetrium, and
parametrium. Certain special indications, however, exist in the case of
chronic uterine infarct, and the discussion of treatment is limited
here to their consideration.
1. Local Treatment.--In view of the pathology of the condition, local
treatment, especially in the first stage, is antiphlogistic.
Hot-Water Vaginal Douche.--The irrigation of the vagina with hot water,
of different degrees of temperature according to the indications in the
concrete case, deservedly occupies the high position in American
gynæcological therapeutics which Emmet[32] in particular has assigned
it. The smooth muscular fibres of the uterus are excited to contract,
and the whole pelvic circulation is directly or indirectly influenced.
During the stage of infiltration--Emmet's congestive
hypertrophy--hot-water vaginal irrigation is simply an invaluable
adjuvant. But to secure the maximum benefit from this remedy it must be
rationally employed. With reference to posture, Emmet recommends the
dorsal decubitus, with elevation of the hips, or, better, the
genu-pectoral position. The temperature of the water should be rapidly
elevated from blood-heat to 110° F., or to as high a degree as the
patient can tolerate. The quantity of water will vary with the stage of
the treatment and the improvement in health of the patient. It is
customary to begin the irrigations with one to two {458} gallons of
water, and to increase or decrease the quantity according to
circumstances. Two irrigations per diem--one at night before going to
bed, one in the morning upon rising--are usually sufficient.
Fritsch[33] has tried on an extensive scale the plan of continuous
vaginal irrigation with hot water through five and even ten hours, but
has obtained better results with the simple periodic vaginal douche as
recommended by Emmet.
[Footnote 32: _Principles and Practice of Gynæcology_, 3d ed. 1884, pp.
85, 113.]
[Footnote 33: _Op. cit._, 1885, p. 337.]
During the stage of induration, when the muscular elements have been
destroyed and replaced by connective tissue, the beneficial effects of
the hot-water douche are decidedly less evident. Nor is the plan
applicable to all cases during the stage of congestive hypertrophy.
General nervous excitement, insomnia, and even positive intrapelvic
pain, sometimes, though rarely, may result. The range of therapeutic
application of the hot-water vaginal douche is largely empirical.
Local Depletion.--The local bloodletting of from a drachm to one ounce
of the fluid, repeated according to the indications every three or four
days, ranks next to the hot-water vaginal douche in importance as an
antiphlogistic agent. This plan of treatment is of especial value as an
adjuvant during the stage of infiltration in cases of menorrhagia,
metrorrhagia, exacerbations of acute inflammation, and the like. Local
depletion, however, is a double-edged sword. It may cause an increased
determination of blood to the uterus and aggravate the pathological
condition already existing. This effect is observed when the
bloodletting is practised at too short intervals.[34] Thus, frequent
scarifications of the cervix constitute a most important therapeutic
resource in the treatment of certain forms of atrophy of the uterus.
[Footnote 34: A. Martin, _op. cit._, 1885, p. 59.]
Local depletion of the cervix is effected by scarification, puncture,
leeches, wet and dry cupping. Scarification and puncture have almost
entirely superseded the other two methods.
Local depletion has fallen into a state of comparative disuse in
America. In the Woman's Hospital of New York[35] it has almost
completely passed out of vogue. In Germany, however, it constitutes the
basis of all methods of treatment. Schroeder, A. Martin of Berlin, H.
Fritsch of Breslau, Carl Braun, Spaeth, and Chrobals of Vienna unite in
enthusiastic advocacy of its intelligent employment in suitable cases.
[Footnote 35: T. Gaillard Thomas, _Diseases of Women_, 5th ed., 1880,
p. 334.]
Glycerin Tamponade.--Sims many years ago called attention to the
employment of cotton tampons saturated with glycerin in the treatment
of chronic metritis and kindred affections. In virtue of its avidity
for water the glycerin tampon, when placed in the vagina, provokes a
profuse aqueous discharge. The albuminoid constituents of the blood are
not affected, while the capillaries are drained of their aqueous
elements. Emmet[36] has substituted oakum for absorbent cotton. Oakum,
when saturated with glycerin, becomes soft as a sponge, is perfectly
antiseptic, and will remain odorless in the vagina a much longer time
than cotton. Glycerin dissolves the salts more readily than water.
Boric acid (1:10), potassium iodide (5:100), iodoform, chloral, and a
variety of substances may be applied locally by means of this
menstruum. Glycerin, employed in conjunction with hot-water vaginal
irrigation and scarification, or used {459} alone in cases
contraindicating these procedures, is an important addition to our
therapeutic resources.
[Footnote 36: _Gynæcology_, 1884, p. 128.]
Local Alteratives.--Much importance is attached in the United States to
the application of various alteratives to the vaginal portion and
endometrium in cases of chronic uterine infarct. They may accomplish
good results indirectly--for example, by curing the accompanying
endometritis--but it is doubtful whether they have any direct effect in
hastening the resorption of the infiltration.
The vaginal vault and intravaginal portion of the cervix are usually
painted with the compound tincture of iodine; mercury, potassium
iodide, iodoform, and other substances are introduced into the vagina
by means of vaseline, gelatin, and cacao butter.
Operative Treatment.--1. Repair of Lacerations of the Cervix.--The
importance of the repair of lacerations of the cervix for the cure of
chronic uterine infarct and allied conditions was recognized by Emmet
in 1862. In the autumn of 1862 he devised and performed the operation,
which is now known the world over as Emmet's operation. This highly
original and valuable surgical procedure has been but little modified
in the years which have intervened since its first full description in
1869.
2. Amputation of the Collum Uteri.--Carl Braun[37] and Wedl in 1864
pointed out the fact that amputation of the neck of the chronically
inflamed uterus is frequently followed by a more or less complete
involution of the whole organ, resembling very closely the reductive
metamorphosis of the puerperal uterus. August Martin in recent years
has called attention to Braun's observation, and at the
Naturforscherversammlung in Cassel described a series of seventy cases
in which amputation of the collum uteri had been performed for the
relief of chronic metritis. As an ultimate resort in extreme cases,
amputation of the neck of the uterus is now a generally well-recognized
operative procedure.[38]
[Footnote 37: _Wiener Med. Jahrbücher_, Wien, 1864.]
[Footnote 38: H. Fritsch, _op. cit._, 1885, p. 343.]
3. Castration.--At a comparatively recent date a determined effort has
been made to include desperate cases of chronic metritis under the
indications for the performance of oöphorectomy. Numerous and
distinguished surgeons have taken this advanced position. But at the
present time the cases in which the operation has been performed are
too few in number and too recent to warrant positive deductions with
reference to the effects of the operation.
2. General Treatment.--It is not possible to adequately discuss the
subject of the general or constitutional treatment of chronic metritis
in the limited space at our command. It is scarcely necessary to add
that the subject is of vital importance, and more frequently neglected
than the local treatment. The indications for therapeutic aid are
usually apparent, and are not always peculiar to the condition.
Attention has been directed, in other portions of this work, to the
importance of the observation of hygienic laws, in the widest sense of
that expression, with respect to diet, rest, clothing, recreation,
personal cleanliness, temperance in sexual intercourse, and other
bodily habits.
Habitual constipation, involving as it does engorgement of the portal
system and pelvic veins, demands especial consideration. In the absence
of regular daily alvine dejections the most elaborate plan of local and
{460} constitutional treatment will fail to effect amelioration of
symptoms. Diet, exercise, and the like are not sufficient, as a rule,
to correct this most obstinate habit. Among remedial agents, senna,
rhubarb, cascara sagrada, and the milder laxatives deserve particular
mention. The compound licorice powder and confection of senna of the
U. S. Pharmacopoeia are comparatively innocent in their effects, even
when used through long periods of time. Aloes must be employed with a
certain amount of caution. As pointed out by August Martin,[39] when
there is a disposition to uterine hemorrhages the drug, in the exercise
of its well-known influence on the pelvic circulation, may increase
this tendency. Clysters may be employed to advantage in connection with
hygienic and medical means.
[Footnote 39: _Op. cit._, p. 195.]
Ergot, hydrastis canadensis, potassium iodide, ammonium chloride,
strychnia, are among the remedial agents which are supposed to have
some direct effect upon the condition of the uterine parenchyma. Ergot
may be exhibited by the mouth or hypodermatically. Squibb's fluid
extract, while an active and tolerably agreeable preparation, is not as
effective as the decoction employed on an extensive scale in many of
the German hospitals, and the formula of which we append:
Rx. Secalis cornuti recent. pulver., 15.0
Alcohol., 5.0
Acidi sulphurici, 2.0
Aquæ, 500.0
Coque ad 200.0
Ne cola.
Adde Syr. cinnamom., 30.0
Dose: Two to three teaspoonfuls, pro re nata. This unfiltered decoction
is extremely distasteful, and its continued use is not without effect
upon the gastric mucous membrane. It is, however, physiologically very
active. Subcutaneous injections of Squibb's aqueous extract of ergot
may be occasionally employed with benefit to keep up the impression of
the remedy when exhibition per os is interrupted. Schatz speaks in high
terms of the fluid extract of hydrastis canadensis in doses of fifteen
to twenty drops two or three times daily.
All European writers ascribe an important influence to the numerous
watering-places and baths of the Continent in the treatment of chronic
uterine infarct. The rigid observance of hygienic rules, the imbibition
of enormous quantities of water more or less impregnated with salines
and carbonic acid, the frequent bathings, exercise, and recreation,
undoubtedly effect amelioration of symptoms in many desperate cases.
Acute Endometritis.
ETIOLOGY.--An acute inflammation of the mucous membrane of the uterus
is a rare affection before puberty. The acute infectious diseases play
an important rôle in the production of the condition. The acute
exanthems--smallpox, measles, scarlet fever, cholera, typhus, typhoid,
and relapsing fever, certain forms of malarial fever--deserve mention
in this connection. Probably owing to some change in the constitution
{461} of the blood, these diseases predispose to the hemorrhagic form
of acute endometritis. The rapid cooling off of extensive areas of the
skin surface during menstruation frequently leads to an acute
inflammation of the endometrium, with suppression of the flow as one of
the first symptoms. Gonorrhoeal infection and sepsis are most important
causative factors. Ill-advised therapeutic procedures, as in the case
of acute metritis, must be included in the list of causative agencies.
Finally, acute endometritis may be caused by various poisons. Among
toxic agents which may give origin to the condition under discussion
phosphorus is especially noteworthy.[40]
[Footnote 40: Hausmann, _Berl. Beitr. z. Geb. u. Gyn._, Bd. i. S. 265.]
PATHOLOGICAL ANATOMY.--The entire lining membrane of the uterine cavity
may be involved in the inflammatory process; usually, the mucosa of the
body and fundus is affected, the mucosa of the cervical canal remaining
normal. The mucous membrane is of a dark-red color, swollen, softened,
and presents a velvety appearance. Its connection with the muscularis
is loosened, so that it can frequently be stripped off with the handle
of a scalpel. Minute extravasations of blood are visible in the
superficial layers and on the surface. The interglandular connective
tissue is the seat of the inflammatory process. The glands are involved
secondarily. The ciliated epithelium is destroyed and cast off at an
early stage. The bloody discharge from the uterine cavity becomes
serous, and finally purulent, during the progress of the condition. The
cervical secretion becomes thin, turbid, and profuse.
The inflammatory process is seldom limited to the endometrium. It
involves, as a rule, the tubal mucous membrane, the uterine parenchyma,
and the perimetrium.
DIAGNOSIS.--The symptoms resemble closely in kind, but differ in degree
from, the appearances in acute metritis. The uterus is smaller and not
so painful on pressure. The endometrium is sensitive to the slightest
touch--a fact elicited upon the passage of the sound. The
characteristic symptom is the discharge from the uterine cavity of a
more or less profuse secretion possessing the character already
mentioned. An absolute differential diagnosis is impossible, nor is it
necessary, seeing that the treatment of the two conditions is nearly
identical.
PROGNOSIS.--Acute endometritis terminates in resolution or chronic
inflammation. The latter mode of termination is of more frequent
occurrence, particularly in the presence of gonorrhoea, sepsis, and the
like as etiological factors. The disease endangers life when the
peritoneum is involved by the propagation of the inflammatory process
along the tubes or through the uterine parenchyma. Then the acute
endometritis may be the starting-point of general septic infection
through the media of the veins and lymphatic vessels.
TREATMENT.--Absolute rest in bed, the relief of pain by morphine, the
evacuation of the bowels by enemata or mild laxatives, the free
imbibition of bland mucilaginous fluids for the vesical tenesmus,--are
measures which usually fulfil all indications for treatment. Even in
the case of gonorrhoeal infections astringent applications to the
endometrium are contraindicated. Usually, various complications mark
the endometritis, the starting-point of the pathological condition, and
these complications demand more active interference.
{462} Chronic Endometritis.
ETIOLOGY.--Attention has been called to the etiology of chronic
metritis in a somewhat detailed manner. The limits of this paper will
not admit of adequate mention even of the more common causative factors
of chronic endometritis. All the conditions which determine an active
fluxion or passive hyperæmia of the uterus may operate as causative
factors. Hypersecretion of mucus is frequently observed in chlorotic,
scrofulous, and tuberculous females. Syphilis and gonorrhoea are
potential causative agents. Climate seems to exercise a more or less
direct influence. Thus, we are informed by Schroeder[41] that chronic
endometritis is observed with relative frequency in damp, cool regions,
such as Holland, Belgium, and certain parts of England. Europeans who
reside in hot climates--for example, the Englishwomen living in
India--are said to be affected with leucorrhoea to a degree entirely
out of proportion to local or constitutional causes.
[Footnote 41: _Handbuch der Krankheiten der Weiblichen
Geschlechtsorgane_, 1881, p. 111.]
PATHOLOGICAL ANATOMY.--An analogy of striking character exists between
the structural changes in chronic endometritis and chronic metritis. In
chronic endometritis, as in chronic metritis, it is possible to clearly
distinguish two stages in the inflammatory process. In the first, or
stage of infiltration, a more or less acute inflammation is observed,
which involves, primarily, the interglandular connective tissue;
secondarily, the glands themselves. When the stage of infiltration does
not terminate in resolution with the resorption of the exudate, the
newly-formed connective-tissue elements contract, and the glands are to
a greater or less degree obliterated.
1. Chronic Catarrhal Endometritis.--The endometrium during the first
stage is swollen, vascular, soft, and succulent. Small extravasations
of blood and pigmentary deposits from ecchymoses are observed in the
interacinous connective tissue. The surface of the mucous membrane is
smooth or roughened in spots. The orifices of the glands are visible.
The mucous membrane of the cervix is infected, its transverse folds
distended, the follicles filled with mucus, the canal plugged with
tenacious turbid secretion; the vaginal portion is enlarged, spongy,
and its mucous membrane exhibits hypertrophic changes in the papillary
body. The os externum is frequently patulous. The uterine walls having
undergone excentric hypertrophy, the cavity is usually enlarged, and
contains a translucent alkaline secretion which resembles mucus.
Microscopical examination of the endometrium reveals a variety of
structural changes. A luxuriant development of embryonal
connective-tissue elements is observed with relative frequency in the
interacinous connective tissue. Olshausen has applied the term chronic
hyperplastic endometritis to this condition. The term chronic
interstitial endometritis has been more generally accepted. While the
newly-formed connective-tissue elements are soft and succulent,
hemorrhages are frequent.
Changes in the glandular structures may become more prominent features
than alterations in the connective tissue. The laminæ of the glands and
the cells of the acini increase in size. The glands branch, frequently
resulting in the production of a dendritic network. Schroeder and Carl
Ruge have termed this glandular endometritis diffuse adenoma.
{463} The thickness of the mucous membrane may increase in spots from
three or four millimeters to fourteen or fifteen millimeters, and there
is produced a form of chronic endometritis which is known as fungoid or
polypoid.
Under the name endometritis villosa Slavianski described in 1874 a
condition of the uterine mucous membrane which consists in a papillary
growth of the endometrium with myxomatous degeneration of the vessel
tunics.
During the stage of induration the ciliated epithelium, destroyed and
cast off during the stage of infiltration, is replaced by cells which
resemble squamous epithelium. The utricular glands, with dilated
cavities, are flattened out, entirely obliterated, or present the
appearance of shallow crypts. The secretion is gradually diminished,
until finally the endometrium is converted into a layer of connective
tissue.
Under the names erosion, ulceration, granulation, and the like a
variety of pathological conditions, entirely distinct from, sometimes
in connection with, cervical laceration and ectropium, are included.
The flattened epithelium covering the vaginal portion may be cast off,
and replaced by the dark-red subjacent cylindrical epithelium, giving
origin to the condition known as simple erosion. Occasionally,
glandular canals, formed out of these cylindrical cells, and
penetrating the mucous membrane in every direction, present the
appearances of papillary erosion; and the condition has accordingly
been termed by Carl Ruge papillary ulcer. Cervical secretions may
stagnate in these glandular tubes, retention-cysts appear, and the
condition technically termed follicular erosion results. In all forms
of cervical erosion or laceration the secretions are increased in
amount and altered in physical and chemical characters during the stage
of infiltration. In a later stage of the disease the hyperplasia and
subsequent contraction of the connective-tissue elements may result in
the total obliteration of all traces of glandular structure. There is a
certain amount of probable evidence in favor of the view that these
changes in the cylindrical cells normally situated beneath the squamous
epithelium covering the vaginal portion may terminate in malignant
disease. These erosions, in the present state of our knowledge, must be
viewed as symptomatic of chronic endocervicitis.
2. Dysmenorrhoea Membranacea.--The exfoliation and casting off of large
pieces, or even of the superficial layers, of the entire endometrium
during menstruation has been observed from the days of Morgagni up to
the present time. Peter Frank pointed out the resemblance between this
exfoliation and the membrana caduca. Simpson, recognizing the
sieve-like perforations caused by the utricular glands, termed the
condition exfoliation of the hypertrophic mucous membrane. Virchow
erroneously termed the membrane decidua menstrualis. Olshausen, Wyder,
and v. Recklinghausen (1877) have demonstrated the truth of Simpson's
view, and have shown that the condition must be regarded as a symptom
of a series of endometritic inflammatory processes. In all cases in
which a decidual membrane is cast off the diagnosis of abortion must be
made, whether the pregnancy be intra-uterine or extra-uterine.
Wyger has reported a case in which syphilis was regarded as an
etiological factor. This observation has not been confirmed.
3. Chronic Croupous Inflammation of the Endometrium is sometimes
observed in connection with carcinoma of the corpus. It may follow
{464} gangrenous vaginitis in diphtheria and the acute infectious
diseases. The interacinous connective tissue is infiltrated with
fibrinous materials, and extravasations of blood are everywhere
visible. The superficial layers of the mucous membrane become
gangrenous, are cast off, and occasionally the entire intra-uterine
expanse is converted into a wound surface.